The nurse is caring for a patient diagnosed with acquired immunodeficiency syndrome (AIDS) whose most recent laboratory values reveal a CD4 level less than 200. Which assessment findings require immediate intervention?
Oral candidiasis and nausea
Genital ulcer and vomiting
Memory deficit and apathy
Progressive dyspnea and fever
The Correct Answer is D
A. Oral candidiasis and nausea: Oral candidiasis (thrush) and nausea are common manifestations in patients with AIDS, particularly when the CD4 count is low. While these symptoms require intervention, they are not typically considered emergent or immediately life-threatening.
B. Genital ulcer and vomiting: Genital ulcers and vomiting can occur in patients with AIDS due to various opportunistic infections and conditions. While these symptoms may warrant intervention, they are not typically indicative of an immediate life-threatening situation.
C. Memory deficit and apathy: Memory deficits and apathy can occur in patients with AIDS, particularly as the disease progresses. While these cognitive and behavioral changes may impact the patient's quality of life and require intervention, they are not typically considered emergent or immediately life-threatening.
D. Progressive dyspnea and fever: Progressive dyspnea (difficulty breathing) and fever are concerning findings in a patient with AIDS, especially with a CD4 count less than 200. These symptoms may indicate the presence of opportunistic infections such as Pneumocystis jirovecii pneumonia (PCP), which can rapidly progress and lead to respiratory failure and death if not promptly treated. Therefore, these assessment findings require immediate intervention to assess for and manage potential respiratory compromise and systemic infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Injection of drugs:
Hepatitis E is not primarily spread through the injection of drugs. While injection drug use can increase the risk of hepatitis B and C transmission, hepatitis E is typically spread through the fecal-oral route, often via contaminated water or food.
B. Semen:
Hepatitis E is primarily transmitted via the fecal-oral route and is not commonly spread through semen. Sexual transmission of hepatitis E is rare compared to other types of viral hepatitis, and the primary mode of transmission is ingestion of contaminated food or water.
C. Fecal-oral:
The fecal-oral route is the primary mode of transmission for hepatitis E. This means that the virus is spread through ingestion of food or water contaminated with fecal matter containing the virus. Poor sanitation and hygiene practices are common risk factors for hepatitis E transmission.
D. Blood:
Unlike hepatitis B and C, hepatitis E is not primarily transmitted through blood exposure. While transmission through blood transfusions or organ transplants has been reported in some cases, the main mode of transmission for hepatitis E is ingestion of contaminated food or water.
Correct Answer is D
Explanation
A. Systolic BP between 120 and 160 mmHg:
While this range represents a moderate level of blood pressure control, it may not be optimal for preventing organ damage in individuals with primary hypertension. Systolic blood pressure (SBP) between 120 and 160 mmHg is considered elevated and may still increase the risk of cardiovascular complications over time. While it's not dangerously high, it's not within the recommended range for preventing organ damage associated with hypertension.
B. Diastolic BP between 70- and 99-mm Hg:
This range for diastolic blood pressure (DBP) is relatively broad and encompasses normal to elevated levels. While DBP between 70 and 99 mmHg is generally considered within the normal to prehypertensive range, it may not fully reflect the target range recommended for preventing organ damage in individuals with hypertension. The upper limit of 99 mmHg is higher than the optimal target range for preventing hypertension-related complications.
C. Diastolic BP between 60- and 79-mm Hg:
This range represents the optimal target for diastolic blood pressure (DBP) in individuals with hypertension. Keeping DBP between 60 and 79 mmHg is associated with reduced risk of cardiovascular events and end-organ damage. It aligns with current guidelines for blood pressure management and reflects successful teaching regarding the recommended range needed to prevent organ damage in patients with primary hypertension.
D. Systolic blood pressure between 90 to 120 mm Hg:
This range represents the optimal target for systolic blood pressure (SBP) in individuals with hypertension. Maintaining SBP between 90 and 120 mmHg is associated with the lowest risk of cardiovascular events and complications. It aligns with current guidelines for blood pressure management and reflects successful teaching regarding the recommended range needed to prevent organ damage in patients with primary hypertension.
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